Physical Therapy DataBase

segunda-feira, 18 de agosto de 2014

The hip is one
of the body’s largest joints. It is a ball-and-socket joint. The socket is
formed by the acetabulum, which is part of the large pelvis bone. The ball is
the femoral head, which is the upper end of the femur.

The bone
surfaces of the ball and socket are covered with articular cartilage, a smooth
tissue that cushions the ends of the bones and enables them to move easily. [1]

A thin tissue
called synovial membrane surrounds the hip joint. In a healthy hip, this membrane
makes a small amount of fluid that lubricates the cartilage and eliminates
almost all friction during hip movement. [1]

Bands of tissue
called ligaments (the hip capsule) connect the ball to the socket and provide
stability to the joint. [1]

Description

“Total” means
that the prosthesis concerns the two parts of the hip joint: the part of the
pelvis (the acetabulum) and the part of the femur (the head of the femur). [2]

In a total hip
replacement, also called hip arthroplasty, the damaged bone and cartilage are
removed and replaced with prosthetic components. [1]The
damaged femoral head is removed and replaced with a metal stem that is placed
into the hollow center of the femur. The femoral stem may be either cemented or
“press fit” into the bone. [1]A
metal or ceramic ball is placed in the upper part of the stem, replacing the removed
damaged femoral head. [1]The
damaged cartilage surface of the socket (acetabulum) is removed and replaced
with a metal socket. Screws or cement are sometimes used to hold the socket in
place. [1]A
plastic, ceramic or metal spacer is inserted between the new ball and the
socket to allow a smooth gliding surface. [1]

When it is proposed?

A total hip
prosthesis is normally suggested when the disability has become severe. Hip
pain that limits your everyday activities, such as walking, bending or getting
in and out of a chair, that continues while resting, either day or night, and
stiffness that limits the ability to move, lift the leg or put on your shoes
and socks, that aren’t relieved by anti-inflammatory drugs, physical therapy or
walking supports, are good indicators to consider a total hip replacement
surgery. [2]

Hip replacement surgery is a safe and effective
procedure that can relieve your pain, increase motion, and help you get back to
enjoying normal, everyday activities. [2]

If, in addition,
the osteoarthritis lesions are very advanced on the latest radiographs, this is
another reason to consider it. [2]

Common causes of hip pain

The most common
causes of chronic hip pain and disability is arthritis, being osteoarthritis,
rheumatoid arthritis and traumatic arthritis the most common forms of this
disease. [1]

Osteoarthritis. This is an age-related “wear and tear” type of
arthritis. It usually occurs in people 50 years of age and older and often in
individuals with a family history of arthritis. The cartilage cushioning the
bones of the hip wears away, causing the bones to rub against each other,
causing hip pain and stiffness. Osteoarthritis may also be caused or
accelerated by subtle irregularities in how the hip developed in childhood. [1]

Rheumatoid arthritis. This is an autoimmune disease in which the synovial
membrane becomes inflamed and thickened. This chronic inflammation can damage
the cartilage, leading to pain and stiffness. Rheumatoid arthritis is the most
common type of a group of disorders termed “inflammatory arthritis”. [1]

Post-traumatic arthritis. This can follow a serious hip injury or fracture. The
cartilage may become damaged and lead to hip pain and stiffness over time. [1]

Avascular necrosis. An injury to the hip, such as a dislocation or
fracture, may limit the blood supply to the femoral head. This is called
avascular necrosis. The lack of blood may cause the surface of the bone to
collapse, and arthritis will result. Some diseases can also cause avascular
necrosis. [1]

Childhood hip disease. Some infants and children have hip problems. Even
though the problems are successfully treated during childhood, they may still
cause arthritis later on in life. This happens because the hip may not grow
normally, and the joint surfaces are affected. [1]

Complications

The risk of venous
thrombosis (blood clots) in the leg veins or pelvis is the most common
complication of the hip replacement surgery. These clots can be
life-threatening if they break free and travel to the lungs. This is easily
surveilled and avoid through anticoagulant therapy (blood thinning medications),
compression stockings, inflatable leg coverings, ankle pump exercises and early
mobilization. [1]

Warning signs of
a blood clot in your leg include [1]:

Pain
in your calf and leg that in unrelated to your incision;

Tenderness
or redness of your calf;

Swelling
of your thigh, calf, ankle or foot.

Warning signs or
pulmonary embolism (blood clot that has traveled to your lung) include [1]:

Sudden
shortness of breath;

Sudden
onset of chest pain;

Localized
chest pain with coughing.

Infection of the
prosthesis is a less common complication that can also occur from a hip
replacement surgery. This is prevented by measures taken before, during and
after surgery. Pre-operatively, a “silent” infection (without symptoms),
urinary or dental, should be sought. During the surgery, very rigorous aseptic
standards must be observed. Lastly, after placing the prosthesis (and sometimes
after several months or years), any distant infection of the prosthesis must be
treated whether pulmonary, urinary or dental. An infection of the prosthesis
requires prolonged hospitalization for an intravenous treatment or, possibly,
replacement of the prosthesis. [2]

Physical Therapy

After a total
hip replacement surgery, an early physical therapy is very important for you to
return to your normal life, doing your normal activities.

The day after
surgery, the physical therapist of the hospital where you are staying will come
to your room and will gently mobilize your operated leg to soften your muscles
and will demand you simple strengthening exercises. After this, he will ask
you to seat at the edge of the bed and, if all goes well, he will ask you to stand up,
with an aid of a walker, so you can lean on to it. After this, the physical
therapist will lay you down on the bed again. This is very important because it
permits you to have a vertical position.

The next days,
the physical therapist, besides keeping mobilizing your hip and strengthening
you hip muscles, will teach you how to start walking with the aid of walking
supports. Initially you will start walking with a walker, then moving on to two
elbow crutches, then one elbow crutch and, finally, with no aids at all or, if
you feel safer, a cane. For a smooth walk with a walker you should advance your
walker, then your operated leg and finally your “good” leg.

For the elbow crutches,
first of all, you need to know how to adjust your crutches. The grip should be at
the same height as your hips, and the semi-elliptical cuff should be at three
to four fingers below your elbow. The rubber cap should have a great adherence
to the floor to prevent you from slipping.

With two elbow crutches you should advance
your two elbow crutches at the same level, then your operated leg, so that your
foot will be between the elbow crutches, and then your “good” leg, a little bit
forward then the foot of your operated leg. When you start to feel surer of
yourself you can progress to an alternate walking, that is, you start by
advancing the elbow crutch opposite to you operated hip and your operated hip, and
then you advance the elbow crutch opposite to your “good leg” and your “good leg”.

After you have
done enough strengthening and mobilization of your operated leg, and if you feel
ready, ask your physical therapist, in the hospital or in a clinic, if you can
now start to use only one crutch. To use only one elbow crutch, your physical
therapist will tell you to keep using the crutch in the hand opposite to your
affected hip. With one elbow crutch you advance your operated leg and your crutch at the same time.

Be sure to tell
your physical therapist if you have stairs at home, so he can teach how to
climb and descend them.

To both climb
and descend stairs, you should to do them step by step. To climb the stairs
first you climb your elbow crutches, then your good leg and, finally, your operated
leg. To descend the stairs you first descend your crutches, then your operated
leg and, finally, your good leg.

If you walk with
only one elbow crutch and you have a stair rail, you can still descend and climb
stairs with the crutch in the hand opposite to the hand rail.

When you get out
of the hospital, you still need to find a physical therapist to continue the
rehabilitation of your new hip.Here is a video that shows you everything that I have just explained to you. I could only find videos with axillary crutches and not elbow crutches, but the principle is the same.

Here is another video that I have found interesting because it shows at the end of the video a way of mobility that you can use when you are going to bed or get out of the bed.

Strengthening exercises

For a good and
normal walk, you need to strengthen all of the muscles that surround the
operated hip, so the joint can be as stable as possible when you walk. The most
important group of muscles are the quadriceps, the hamstrings and the gluteus
medius. These muscle groups work together to support and stabilize the pelvic
girdle. Without this support we would not be able to walk or move freely.

Below I will show you some videos of simple exercises that you can do at home. Before doing any
of these exercises at home, be sure to ask your physical therapist, for he is
the only one that knows what your conditions are. He can also advice you of the
weight-bearing you can or cannot do.

You can do 3 series of 10 repetitions, resting between series. Later, if the exercises become easy, you can add a charge on your ankle, beginning in 0.5 Kg to 2 Kg max, progressin little by little. Ask your physical therapist if and when you can add the charge.

Balance exercises

For even better
total hip replacement rehabilitation, it is also very important to do some
balance exercises. You can do simple balance exercises at your home. All you
need is a chair. You can support yourself in the back of the chair while you
lift you good leg up, nice and gently. With your leg up, you can slowly remove
your hands from the back of the chair. Be aware of keeping your hands near the
chair, in case you lose your balance. When you are stable doing this exercise, you can try to do it with your eyes closed, if you feel stable. If that causes you excessively pain, stop
what you are doing and consult your physical therapist before continuing. If
not, repeat this exercise 3 series of 10 repetitions, resting between series.

Like the
strengthening exercises, check your physical therapist before doing these
exercises, for balance exercises can be more dangerous if they are not done
correctly or at the right time. If you cannot put 100% charge on your operated
leg, you cannot do this exercise.

Swelling

Swelling of the
hip and leg after a hip replacement is normal. However, there are some things
that you can do to minimize this problem. Ice the hip frequently, three times
per day, 20 minutes each. Also ice after you have done your exercises.

If you have swelling
of the entire leg is also normal. This will slowly improve, but there are
various ways to help minimize the swelling:

Lie
down and elevate the leg on several pillows. To effectively reduce swelling,
your foot should be above your heart.

Use
compression stockings.

Do your
ankle pumps. This makes your muscles help remove some of the swelling.

Avoid
prolonged periods of sitting.

Dislocation

This occurs when
the ball comes out of the socket. The risk for dislocating is greatest in the
first few months after surgery while the tissues are healing. Dislocation is uncommon.
If the ball does come out of the socket, a closed reduction usually can put it
back into place without the need for more surgery. In situations in which the
hip continues to dislocate, further surgery may be necessary.

This is prevented
by strengthening the muscles around the prosthesis and avoiding “false moves”
or certain actions in the months following the surgical procedure.

The movements
that are to be avoided are:

- Movements
of internal rotation, like putting your shoes; movements of adduction of the
hip, like when you are sleeping over the good side; or the two movements
combined, like crossing of the legs when seated. To facilitate putting your
shoes you can buy a shoe-horn. To prevent the adduction of the hip while
sleeping, you can use a pillow between your knees.

- Movements
of flexion of the hip more than 90 degrees (lift your knee above your hip).
That’s why you should never seat in a really low chair or crouch down to pick
something of the floor. If you have to pick something of the floor, you move
back your operated leg and you pick up the object in the floor, by bending the
knee of the “good” leg, while you keep the operated leg extended.

In the image above it says 100 degrees, but I advise you 90 degrees (sorry, it was the best image I have found).

Driving an automobile

-

You
are allowed to operate an automobile when you are comfortably walking with crutches
and you have a good and comfort movement of the hip. But first, ask your
physical therapist if you can start driving. To initiate driving, it is advised
to practice in a place where there is no traffic, so you can move the foot of
your affected hip between pedals at ease. To enter safely in the car, you
should seat with the legs out of the car and pivot to the interior of the car.

Home planning

Several
modifications can make your home easier to navigate during your recovery. The
following items may help with daily activities: [1]

Securely
fastened safety bars or handrails in your shower or bath;

Secure
handrails along all stairways;

A
stable chair for your early recovery with a firm seat cushion (that allows your
knees to remain lower than your hips), a firm back and two arms;

A
raised toilet seat;

A
stable shower bench or chair for bathing;

A
long- handled sponge and shower hose;

A dressing stick, a sock aid and a
long-handled shoe horn for putting on and taking off your shoes and socks without
excessively bending orrotating your new
hip;

A
reacher that will allow you to grab objects without excessively bending of you
hip;

Firm
pillows for your chairs, sofas and car that enable you to sit with your knees
lower than your hips;

Removal
of all loose carpets and electrical cords from the areas where you walk in your
home.

Results

The list of
complications should not make you forget that, in most cases, the patient’s
life is transformed by the procedure. The absence of pain and recovery of a
normal joint movement is accompanied by a return to usual activities (before
the hip osteoarthritis) and a return to autonomy. [1]

Expectations

Total hip
replacement is a great operation. It is highly predictable in terms of
improvement in pain, function and quality of life. However, you must be patient
to achieve many of these wonderful benefits of the surgery. The high quality
pain relief that characterizes a good total hip replacement frequently takes,
at least, 6 months. Patients predictably improve for up to a year after a hip
replacement. [1]

[1] American Academy of Orthopaedic Surgeons. Total Hip Replacement. OrthoInfo.org

sábado, 19 de julho de 2014

Other exercises that can relieve sciatic pain are
strengthening exercises. The most important group of muscles that have a great
impact in the improvement of the sciatic pain is the abdominal group.

The abdominal muscles are located between the ribs and
the pelvis on the front of the body. The abdominal muscles support the trunk,
allow movement and hold organs in place by regulating internal abdominal
pressure.

There are four main abdominal muscle groups that combine to completely
cover the internal organs:

Transversus abdominus, which is
the deepest muscle layer. Its main roles are to stabilize the trunk and
maintain internal abdominal pressure;

Rectus abdominus that goes
from the ribs to the pubic bone ate the front of the pelvis. This muscle has
the characteristic bumps or bulges, when contracting, that are commonly called
the “six pack”. The main function of the rectus abdominus is to move the body
between the ribcage and the pelvis.

External oblique muscles that are on
each side of the rectus abdominus. The external oblique muscles allow the trunk
to twist, but to the opposite side of whichever external oblique is contacting.
For example, the right external oblique contracts to turn the body to the left.

Internal oblique muscles that flank
the rectus abdominus and are located just inside the hipbones. They operate in
the opposite way to the external oblique muscles. For example, twisting the
trunk to the left requires the left internal oblique and the right external
oblique to contract together.

Think of your core as a strong column that links the upper body and lower
body together. Having a solid core creates a foundation for all activities. All
our movements are powered by the torso – the abdominals and back work together
to support the spine when we sit, stand, bend over, pick things up, exercise
and more.

Another muscle that is involved in moving the trunk is the multifidus. This
is a deep back muscle that runs along the spine. It works together with the
transversus abdominus to increase spine stability and protect against back
injury or strain during movement or normal posture.

Transversus
Abdominus strengthening

Transversus
abdominus is the deepest of the abdominal muscles and wraps around the abdomen
between the lower ribs and top of the pelvis, functioning like a corset. When
transversus abdominus contracts the waist narrows slightly and the lower
abdomen flattens. The function of the transversus abdominus is to stabilize the
low back and pelvis before movement of the arms and/or legs occurs.

Mid or low
back pain (for example, trauma, sciatic pain, lumbar herniation disc), abdominal
injury/surgery and/or excessive lengthening due to pregnancy can cause a delay
or absence in the anticipatory contraction of transversus abdominus. If this
muscle contraction delay/absence is not corrected, this dysfunction will
remain, even after your pain has subsided.

For that,
you need to restore your recruitment patterns (order in which different muscles
contract). The first step is to learn to isolate the muscle and train it to
contract.

Recruitment
Training for Transversus Abdominis (TrA)

To activate your Transversus Abdominus, all you need to do is “suck in”
your belly about 25% to 50%. To know if you are activating the desired muscle,
just place your index finger slightly inwards from the left and right hip bone.
The hip bones are two bony prominences in front of the waist. Breathe in
and on the breath out contract the transversus abdominus.

Hold the
contraction for 3 - 5 seconds and then release and breathe throughout this
exercise. Repeat the contraction and hold for 3 sets of 10 repetitions 3 - 4
times per day for 4 weeks.

Once you can
easily recruit Transversus Abdominus you can progress to the following
exercises.

Lying on
your back with your knees and hips flexed:

Slowly let your right
knee move to the right, keep your low back and pelvis level. Return to the
center and repeat with the left.

Lift the right foot off
the floor keeping the knee bent. Don’t hold your breath and don’t bulge
your lower abdomen. Return the foot to the floor and repeat with the left
foot.

Lift the right foot off
the floor and then straighten the leg only as far as you can control your
core without lifting your lower back from the floor. Slowly bend the knee
and return the foot to the floor. Repeat with the left leg.

Lift the right foot off
the floor and then the left foot off the floor. Alternate leg extensions,
exert with exhalation, breathe in to rest or hold. As always, do the leg
extensions as far as you can without lifting your lower back from the
floor.

In side lying:

Keep your ankles together
and lift your top knee (only as high as you can control without breath
holding), focus on turning your inner thigh outwards. Return your knee.

With all
these exercises maintain the leg lift for 10 seconds, build to 3 sets of 10
repetitions before moving on.

Once you can
activate the Transversus Abdominus, you can practice recruiting it in many
different positions such as sitting, standing, squatting, lifting etc.

It is not
uncommon for other muscles to co-contract in an attempt to compensate for a
dysfunctional core. It is critical that you take the time to focus on your
technique and achieve a correct contraction before moving on to any loading
through the arms or legs. Watch for the following substitution strategies:

Posterior tilting of the pelvis

Bulging of the abdomen

Depression of the rib cage

Breath holding

Fingertips being pressed
out by a strong muscular contraction (internal oblique)

The final
step is to remember to use this muscle during regular activities. Each time you
get out of the chair, lift, bend or reach, the deep muscle system should be
working with and for you. The goal is to help the brain remember to use the
deep system and the more you use it, the less you will be likely to lose it.

Now, if you
want to, you can go to the gym and train your abdominals. But be sure to ask
your physical therapist about the type of abdominal exercises you can or cannot
do. For example, for people with a lumbar herniated disc it is dangerous to do
all kind of exercises that require a torsion movement of your back.

Other
exercises that can reduce your lower back pain are strengthening of the gluteus
and stretching of the iliac psoas. The stretching of the iliac psoas should be
done at least three times per day with three sessions of thirty minutes each.